GW1-2021-07098_Well Construction - GW1_20210915

I FrnittForm;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Raymond Brown 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
181 ft- 182 ft.
2313 212 ft. 213 ft.
NC Well Contractor Certification Number ,15.OUTER CASING for multi-cased!tells)OR LINER d a Qcable
Raymond Brown well Company, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name G G 0 ft. 70 rt. 6.1/4; In' Sdr21 pvc
prw1202101676 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc.) ft. fL 'in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 22 ft* bentonite pour
Monitoring Recovery 0 ft. IL cement pour
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessar
Geothermal(Heating/CoolingReturn) Ell Other(explain under#21 Remarks) FROM TO DESCRIPTION(rntoq hardness soiVrock e, rain size etc.
p ft. ft. soil
4.Date Well(s)Completed:6/15/2021 Well ID# 0 ft. 60 ft. soil/sandrock
5a.Well Location: w ft. 305 ft. blue granite
Michael Harrell ft. fL `
Facility/Owner Name Facility ID#(if applicable) ft. fL �
286 Farm Brook Rd.
Physical Address,City,and Zip ft. ft [
SUrfy 21.REMARKS L , rPS5%t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
N W Q- �,W(�1 7/23/2021
6.Is(are)the well(s)(3Permanent or Temporary Signature of Certified Well ontractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well' E]YeS or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 55 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 15 Method of test: Sight 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: Hth Amount' 16 completion of well construction to'the county health department of the county
where constructed. I
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016